The synergistic effect of dexmedetomidine on propofol for paediatric deep sedation

Abstract

BACKGROUND Propofol and dexmedetomidine are used separately, and sometimes together, for paediatric deep sedation. Although their combination has been described in adults, the effect of dexmedetomidine as a potential synergist in children has not been studied before. OBJECTIVES The primary objective was to compare the propofol requirements of children who receive propofol alone with those who receive it in combination with dexmedetomidine for deep sedation for upper and lower endoscopic gastrointestinal procedures. DESIGN This was a prospective, open-label, randomised study comparing patients who received propofol alone (group P) with those who received dexmedetomidine and propofol (group DP). The depth of sedation was titrated to a target bispectral (BIS) index. SETTING A Gastroenterology Procedure Unit at a single, tertiary care academic medical centre from April 2018 until December 2019. PATIENTS Eligible patients were scheduled for upper endoscopy, lower endoscopy or both. A total of 39 patients were enrolled (20 DP) and (19 P). INTERVENTIONS Patients in Group DP received dexmedetomidine 0.5 μg kg−1 administered over 1 min followed by an infusion of 0.15 μg kg−1 h−1. In both groups, intravenous propofol was given in bolus increments titrated to a BIS index of 40 to 50 and then a continuous infusion of propofol to maintain BIS at 40 to 50. MAIN OUTCOME MEASURES The primary outcome measure was propofol requirement in each group. Secondary outcome measures were time to achieve the targeted sedation depth, time to achieve an Aldrete recovery score of 9, duration of sedation, mean BIS values, adverse events, ‘PAED’ scores and time to discharge from the postanaesthesia care unit (PACU). RESULTS The median (range) total dose of propofol was 0.23 (0.10 to 0.50) mg kg−1 min−1 in group DP and 0.40 (0.20 to 0.50) mg kg−1 min−1 in group P (P = 0.0004). Time of discharge from the PACU was 60 (20 to 121) min in group DP and 63 (46 to 91) min in group P (P = 0.0409). CONCLUSION The combination of dexmedetomidine and propofol for paediatric procedural sedation achieved a significant reduction in median propofol dose and a slightly shorter median time to discharge from PACU. Large-scale studies may determine whether this reduction decreases the risk of significant adverse events. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02952222

Trends in Pediatric MRI sedation/anesthesia at a tertiary medical center over time

“…21 However, in children undergoing upper and lower GI endoscopies, the use of low-dose dexmedetomidine with propofol was found to be associated with a significant reduction in propofol dose and a possible decrease in time to discharge. 22 In our data, we noted a slightly longer time to discharge in the propofol +dexmedetomidine and propofol +other adjucts groups compared to propofol alone, but this difference in time (7-8 min on average) is unlikely to be operationally significant in all but the busiest imaging centers.…”

ED 50 and ED 95 of propofol combined with different doses of esketamine for children undergoing upper gastrointestinal endoscopy: A prospective dose‐finding study using up‐and‐down sequential allocation method

“…4 It is suggested in some studies that coadministration with other anaesthetics, ketamine for example, may counteract side effects caused by propofol. 5 Ketamine, an N-methyl-D-aspartate receptor (NMDAR) antagonist and a racemic mixture including (S)-ketamine (esketamine) and (R)-ketamine, except for its best known dissociative anaesthetic properties, also provides effective analgesic, anti-inflammatory and antidepressant effects. 6 Ketamine has irreplaceable advantages in paediatric anaesthesia for its maintenance of spontaneous breathing and sympathomimetic properties.…”

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

“…Length of ICU stay and mortality rate were similar amongst the groups [ 15 ]. In children, dexmedetomidine is synergistic with propofol, decreasing propofol requirements by up to 50% when used for procedural sedation for gastrointestinal endoscopy [ 166 ]. An open-label, pilot, prospective, multicenter, randomized controlled trial with dexmedetomidine was designed to evaluate the sedation of mechanically ventilated children.…”